Getting paid is a complex problem for todays healthcare organization

By Moliehi Weitnauer | Posted: 11/07/2016

By Moliehi Weitnauer, Vice President, Claims Management; and, Janett Checo, Principal Solutions Expert, Claims Management,  nThrive

While the Affordable Care Act (ACA) has helped to bring approximately nine million newly insured Americans into the health care system, it has also created an unprecedented level of increased complexity for today’s provider. Getting paid means contending with an increasing number of payer offerings versus yesterday’s handful of insurance plans, each bringing a unique set of rules to adhere to. While standardization is certainly part of a longer-term solution, efforts are in their infancy and won’t bring much needed cash through the door in the immediate future.

The problem is compounded by four key factors:

  1. Changing regulatory requirements such as the shift to ICD-10, make coding compliance even more difficult.
  2. Evolving value-based payment models like Comprehensive Care for Joint Replacement (CJR), require hospitals in designated areas to manage an entire episode of care through a bundled scenario, which is enough to challenge even the best patient accounting system.
  3. Expanding diversity in care settings creates the need to manage to both acute and professional payer rules, however patient accounting systems lack the content needed to ensure compliance.
  4. Managing multiple technology applications that are not well integrated makes it difficult to get a bill out on a timely basis.

Needless to say, sorting through this maze has resulted in a host of billing inefficiencies, with multiple hospital departments often touching a bill before a claim is created and scrubbed for missed errors. This lengthens the time a bill remains in the hospital system and a claim is created, with no guarantee, depending on the quality of the “scrub,” that it will clear when it finally reaches the payer. Worse yet, without good screening your organization could submit a claim twice and trigger a recovery audit contractor (RAC) visit, resulting in the need to assemble and share three years of claims data for improper payment review.

The financial impact of denied claims on health care organizations is considerable. In fact, for the average hospital, denials represent 10 percent to 12 percent of total hospital cases. The magnitude of lost revenue also is alarming. For instance, if a provider submits $300 million in claims and 10 percent or $30 million are denied, it’s a big revenue hit with more time and staff resources required to resolve the denial issues. Often, when denied claims are reexamined it is a rule change that wasn’t comprehended in the scrub due to incomplete or outdated information.

How can health care organizations streamline their billing and claims management process to reduce the time a bill lingers in their system and a claim is cleanly submitted for payment? It is important to have access to a thorough, continuously updated edit set higher upstream in your billing process for accelerated claims reconciliation. Embedding such technology into your electronic hospital record (EHR) system can put accurate information at your fingertips, in effect enabling you to do an initial “scrub” to catch and resolve issues earlier on prior to sending claims through a clearinghouse for a final review. In addition, it offers a single repository to make it more efficient to retrieve claims data, in the event of an audit.

Getting paid requires the ability to provide for claims accuracy and adherence to payer rules. The best way to ensure claims meet requirements for payment is automation of claims screening through robust claims editing technology that covers the acute and professional spectrum.

nThrive (formerly MedAssets-Precyse) ranked #1 in claims management for the “2015/2016 Best in KLAS” report. Our differentiation in the market includes:

  • Edits that address the diversity of payer requirements across 45 of 50 states
  • 5000 professional edits and 23,000 institutional edits
  • <2 percent average claim rejection rate

Contact a specialist at 678.323.2500 to learn more on how you can use comprehensive editing technology from nThrive to help maximize reimbursements and prevent denials.